What is Risk Adjustment and Why is it Important?

We want to work with you to make sure our members to get the care they need to achieve their best health. This is how we improve care for our members, and how we can help build a stronger, healthier New Jersey.

Every time you submit an encounter form with appropriate coding for one of our members, it helps us determine a member’s health status and which members may need extra help. That’s why it’s required for every member service or visit, even if the service is capitated.

Encounter forms also enable us to document members’ health status for New Jersey’s Risk Adjustment Payment Model, which is used to distribute state Medicaid funds to health insurance carriers in proportion to the severity of illness of the members enrolled with each carrier. We submit all encounters to the state to estimate the prevalence of disease in the population we serve. Encounters are the only measurement the state uses to identify chronic illness.

Our clinical staff reviews encounters for chronic illness diagnosis codes to identify high-risk members with chronic illness. Regardless of why a patient seeks care, please document the diagnosis and treatment codes in the patient’s medical record and on the encounter form. Any patient with a chronic illness should be evaluated at least twice a year.

Remember to:

• Encourage members to visit your office regularly, especially those with chronic illness.
• Document and submit encounter forms for all Horizon NJ Health members, including those for capitated services.
• Submit an encounter form to Horizon NJ Health, even if a member has a different primary insurance carrier.

For more information on Medicaid Risk Adjustment, visit the Chronic Illness and Disability Payment System (CDPS) website.

We want to help you provide quality care to our members. If you have any questions, please call our Medicaid Risk Adjustment Program at 1-800-682-9094, ext. 89625, or email ClinicalRiskAdjustment@horizonblue.com.